the thoughts of a surgeon in the notorious province of mpumalanga, south africa. comments on the private and state sector. but mostly my personal journey through surgery.

Sunday, September 09, 2007

boerhaave

i had just started my mo year in surgery. i was going to save lives. i was going to make a difference. nothing could disillusion me.

it was my second day and first call. it was surprisingly quiet, probably because the entire population of pretoria was at the coast for the december holiday. then the thorax guys called us to see a patient. i followed my senior, knowing i would be of little help in any situation at this junction in my career. (i had just come out of the bush where i did my internship and community service years. in fact, i had only recently begun to walk on my hind legs and was just mastering rudimentary tools)

the guy was admitted just after christmas (about 6 days previously) with severe chest pain and a left sided 'pleural effusion'. they had placed an intercostal drain and drained a bubbly type of foul smelling liquid. and thus he had remained for almost a week. the only change was that the drainage became much more offensive.

my senior asked him about christmas. how much he had eaten and how drunk he had gotten. had he vomited etc. the patient, although in severe pain, answered that it had been a party to remember. he could remember very little of it. he had vomited copious amounts though and that's when the pain started.

the patient looked up at my senior and said, 'please help me doctor. i can't take much more of this' 'don't worry, we'll help you. you're going to be just fine.' and with that, we turned and left. this is what i signed up for. we were going to get this guy through whatever was wrong. i was, indirectly going to make a difference. i felt excited. 'that guy is dead!' says my senior as we walk away. i was floored. hadn't he just moments ago told the patient he was going to be ok and given a creepy smile of reassurance? hadn't he held the guy's hand and given a squeeze when the patient said 'thank you doctor, thank you so much'?

we got him to theater. the consultant came out. we opened the chest and found that the esophagus as well as the surrounding tissue was necrotic. it had the dirty dishwater appearance that i would later associate with necrotising faciitis. we debrided, but it is a difficult place to debride. you don't want to debride the heart, for instance. it could cause an unpleasant bleed. i was too junior and too far down the table to really follow the finer details of the operation, but we did deliver him, sort of alive, to icu. they pumped precious money and resources into him for a further two days before the inevitable.

he had boerhaave syndrome, a tearing of the esophagus, usually into the left hemithorax, associated with overeating and drinking which in turn causes discoordinated vomiting and voila! if you diagnose it immediately and operate, they have a chance (fair to good). if you give the sepsis time to set in, causing a mediastinitis, the chances drop. if necrosis of the mediastinum has been allowed to develop, no chance at all.

i was totally dissillusioned. my first call and i stood there innocently believeing in our noble profession while my senior lied to someone. ok, the guy maybe felt better emotionally in the last moments of his life, but i could not justify lying to the guy. i also realised there are some fights you just can't win.

10 comments:

I don't believe that one should ever lie to a patient. It's unacceptable. Some doctors believe it's in their best interests or for their own good. That's too much of a paternalistic view for my liking.

The old Greek's adage ends in "...to comfort always." Although a doctor's aversion to the misinformation of a patient is laudable and something I ascribe to, one wonders whether a patient who is about to die suddenly (i.e. without having had the opportunity of talking / discussing / explaining / ”counselling” - the new buzz word) will want to enter into a philosophical discussion about this with the doctor.

(The paragraph “The death of an admiral” under the heading BOERHAAVE: HERMAN at the very interesting website www dot whonamedit dot com - I must apologise, I'm not au fait with linking and copyright etiquette – is worth a read.)

I remember in my 4th year as a medical student standing in a room watching a bunch of residents and cardiology fellows ponder over the rhythms of a woman who was clearly dying while the family stood outside. I was appalled. Death is going to happen. We can put it off, but cannot avoid it. There are times to comfort, but if someone is dying, they need to be prepared (as do the family members).

That encounter changed my way of dealing with death. I am sure yours did the same for you.

It is indeed a terrible event. I think I had about a 50% success rate: a small tear, diagnosed early, can turn out OK. The patient you describe had no chance. Forturnately for your patients, your disappointment didn't turn you away from your chosen profession.

I remember seeing an eighteen year old girl who got nec fasc of a c-section incision a few days after giving birth. My reg had already told us she was toast, but I remember while I was drawing blood on her or something I told her everything was going to be ok. She smiled at me, and I felt good, and she also seemed to feel a bit better. Of course, she died in ICU a few days after the initial debridement, never having woken up after being put to sleep. I felt terrible for a really long time afterwards.

If it was me with mediastinal nec fasc, would I want my surgeon to tell me that he thought I was going to die, but then allow him to put me to sleep anyway, knowing that I'll probably never wake up? I don't think so. But I also wouldn't want to be put under with my family thinking everything is going to be peachy.

These days, I just say 'You're really sick, but we're going to see what we can do for you.' I don't know if that's the right thing to say either, but it works for me for now.

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the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.